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Partners Home Care Plays Key Role in Cardiac Disease Management Program

Over the past five months, Partners Health Care Systems' Heart Failure Committee has been developing a Heart Failure Program, that is setting the standard for PHS's Disease Management Signature Initiative. The goal of the program is to integrate patient care interventions across PHS's entire continuum of care. The program's model, built upon PHS's strategic management of quality, utilization and cost, will also be used to expand disease management programs across the continuum.

The Committee, chaired by Tom Elliott, Director of Business Development at PHS, is comprised of Leslie Vickers, RN, PHC's Director of Program Development, Peg Goldfarb, RN, PHC's Director of Marketing, members of Partners Community Healthcare, Inc., Nurse Practitioners from Massachusetts General Hospital, Brigham & Women's Hospital, North Shore Medical Center and Newton-Wellesley Hospital, along with Heart Failure Coordinators and Cardiac Physicians throughout the network.

The Committee is impressed by PHC's cardiac procedures and protocols and values PHC's participation in this very important initiative.Some objectives of the Committee have included:

• To choose a model that would expand upon the current PHS Nurse Practitioner Cardiac program by incorporating PHC, a Cardiac Service RN and the development of a new Call Center that will reach more patients who may require further types of cardiac monitoring and education.

• To develop interface and collaboration amongst PHS's Heart Failure Program, the Signature Initiative Complex Case Management Program and Partners Home Care.

• To improve role clarity among Nurse Practitioners, PHC and Complex Case Management Staff.

• To develop system-wide Outcomes Management of cardiac patients.

• To provide ongoing cardiac education throughout the continuum.

PHC is very proud to have an instrumental role in the development of this very significant program.